This week, CMS released the proposed rule which outlines the 2018 performance year requirements of its Quality Payment Program (QPP), under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).

For small practices, it should be seen as a major win, early observers of the rule say. CMS created a number of flexibilities in the QPP that will allow practices with 1 to 15 physicians (its definition of small) to either skip participation altogether or have an easier time adhering to the guidelines.

The American Medical Association (AMA) praised the rule shortly after it was released.

"In proposing these rules, [CMS] has taken another step to make sure the promise of MACRA – where physicians are rewarded for improvement and for delivering high-quality, high-value care – will be fulfilled. Patients and physicians will benefit from the new MACRA approach, as flexibility is vital when implementing a wide-ranging reform," AMA President David Barbe, MD, said in a statement.

MACRA's Merit-based Incentive Payment System (MIPS) aims to either reward or penalize Medicare physicians based on how they perform in four categories: Quality, Cost, Improvement Activities, and Advancing Care Information (ACI). MACRA also includes an option for involvement in an advanced alternative payment model (APM), which includes a 5-percent payment bonus for eligible clinicians.

Here are some of the flexibilities offered by CMS in this proposed rule, along with the other major takeaways for practices:

1. Low-Exemption Threshold Increased

While CMS seemingly* didn't continue its "pick-your-pace" method of flexibility from the current performance year, which allowed practices to submit a minimum amount in order to not receive any penalties, it did increase the low-exemption threshold. Originally, the threshold to skip MIPS was if practices had fewer than $30,000 in Medicare Part B allowed charges or fewer than 100 Part B beneficiaries. That number was upped to $90,000 in Part B allowed charges or fewer than 200 Part B beneficiaries.

*Editor's Note: A CMS spokesperson confirmed to Physicians Practice that it's continuing to propose flexibilities, similar to the "pick-your-pace" method of flexibility from year but not the exact same one. In year one, eligible clinicians could submit one quality measure, minimum ACI requirements, or one improvement activity, and not receive a penalty. In year two, they have to complete one category (ACI, Improvement Activities, or Quality), in order to avoid penalty. The performance threshold goes from 3 points in year one to 15 points in year two.

"Clinicians that are not ready to participate in the 3 (of 4) categories, with the increase performance period proposals, could still do well in the program overall by focusing on the performance category that is most important to them," the spokesperson wrote in an email.

2. Optimism Abounds

The end of the 1058-page rule includes impact analysis, where there is a lot more optimism on how practices will fare than last year. For the 2017 proposed rule, CMS predicted that approximately only 13 percent of solo docs and 30 percent of small practices (2-9 clinicians) would receive a positive payment adjustment under MIPS. With the added flexibilities for the 2018 reporting period, it's predicting that 80 percent of small practices will receive a positive or neutral payment adjustment. Moreover, CMS predicts 90 percent of eligible practices (those that do not meet the exemption), will participate.

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